Got Denied:c

Hi everyone! Well I am very sad and discouraged. Last week I received a letter from BC/BS that I got denied. I was so excited that I already had chosen Dr. Cahill for my surgery after months of searching, now this. Any suggestions are welcome please. I heard about appealing, but I don't know where to start. Please help!

Well first we need to know WHY you were denied. BC/BS is a STICKLER - just read my profile!! first thing is to make sure your policy COVERS wls. If there is an exclusion - I am sorry, but it will be really hard to fight. If it does cover it - then pull a copy of the policy. You must met each and every criteria, or they will not pay! If you give us more information - we can let you know where to start!

Hi Peppermint, Well I think I am missing the 12months diet program. And I don't have many of the diseases they list. I only only only have diabetes, high cholesterol, and I am 200lbs over weight. What else do they want? These people want me to be dieing or what I already have problems with my weight . What I faxed them was a 5 year diet program I did, but it wasn't consecutive I also faxed them the physiatrist (sp) evaluation. What else should I do? Thank You for your help. Thanks a bunch. Maria M.

I have spoken to BCBS in detail about what exactly it is they want. However, the Best bet is to ALWAYS check with your provider at every step along the way to make sure you are meeting thier requirements. As I said, I submitted ALL this - in a binder with EACH requirement labeled in a seperate section and STILL got denied (my BMI in June of 2001 fell below 40, so i did not have the "5 year history" they required ) i wish you lots of luck - I have seen people get approved from them with MUCH less detail and without the 12 month diet, but it seems to depend on your policy and the relationship your employer has with them. --Each visit must be on a separate sheet and list your current weight and vital signs (meaning blood pressure, pulse, whatever else,etc). The doctor must also make notes about your diet and exercise within that period of time as WELL as any lifestyle changes within that time (like taking the stairs instead of elevator and switching to whole wheat bread or lowfat milk- stuff like that) --You MUST see the doctor (or a nurse practicioner) EVERY MONTH for 12 months in a row. You can not skip a month and you You can not just go in for weight checks, you must review your plan with someone each time and they must write PROGRESS NOTES on the chart. Your weight (and issues resulting from your weight) must be the ONLY thing discussed at the visit and noted on your chart. --They want you to see a nutritionist at EVERY visit - or at minimuim every three months on the plan. The nutritionist must document what was discussed and goals for the next month. --They also want you to see a physical therapist at minimium every three months on the plan. (I asked if the YMCA would be ok for this and she stated that if I had someone SIGNING off on my cards that I was there and Listed the beginning and ending times that would probably be OK) --They want you to see a psychologist at minium at the beginning and ending of the 12 month plan. --Ideally they would also like you to be on some kind of liquid diet plan or weight loss drug. If your PCP decides that is NOT safe for you then he must STATE WHY he feels that is not a good option in the chart.

Thank you so much for your help, Peppermint. I will start going to the nutritionist as soon as they get me in. God bless you. Maria M.

Peppermint, I am new to all this. I have bc/bs of ill. and just found out that my comp. I work for doesn't cover gastric bypass.I have been on every acid reflux med out there for the past 10 yrs. my stomach dr. referred me to the W/L dr. To make a long story short, if I dont have this surgery I will eventually get throat cancer.what am i going to do???

I am sorry you are going through this. if you are asking for my advice on BCBS - the only advice I can give is get a new insurance carrier! After years of fighting with them - I ended up getting a new job JUST to get WLS covered. Athough that did not work well for me either! if there is an exclusion on your companies policy - you are going to have a very rough fight on your hands getting them to approve. I had the coverage AND met all thier requirements and STILL got denied. Can you switch carriers during open enrollment? Can you talk to your company about adding it to your policy? can you afford to take out a seperate policy on yourself - or even self pay? I am probably not the best person to ask - as I have not been sucessful at getting coverage either, but don't give up. if it was meant to be - it will happen! Good luck patty

hello! I'm sorry to hear you got denied. I know the feeling! I was self-pay! Find out why you were denied. I'm sure you've done your homework on the surgery as well as your insurance carrier. Are there any exclusions on your policy? If not, fight them! There was an exclusion on my policy which made it next to impossible to win. But I've heard many many countless stories on here of people overturning a decision even when there was an exclusion. Either way, God bless you in your journey and Dr. Cahill is a great surgeon...And it doesn't hurt that he's a hottie!!! :0)... Take care and don't get discouraged.... Gracie

Hi Gracie! Thank you for your encouragement. I won't give up I am going to keep trying 'til I get approved. And how are you doing? Are you still losing weight and any complications? Take care and God Bless you,too. Maria Murillo

Hi Maria, I am having my surgery on Tuesday. It will be 2 years since I began the journey. I was denied several times. I met the criteria and they still denied me and kept telling me things were not met. My advice is keep fighting. Get copies of all your records of things submitted from your docs. Document every conversation with BCBS. Write down the date, time and name of the person you spoke to. I eventually called the President of BCBS's office and told them I wanted to file a complaint or law suit. I got in touch with someone who I told my saga to and the hoops I had to jump through. I pointed out where in the information sent to them by my doc's office things were that were supposedly not met and finally my appeal was approved. As I see it, they say it can be covered if you meet the criteria, but this is to avoid a discrimination lawsuit. They make it so difficult that you want to give up. I was lucky to have great support from the staff at my doctor's office. I wish you the best of luck. Keep fighting for what you deserve. Jodi